Original Research

Community Nursing Home Program Oversight: Can the VA Meet Increased Demand for Community-Based Care?

Fed Pract. 2023 October;40(10):338 | doi:10.12788/fp.0421

Author(s):

Background: The US Department of Veterans Affairs (VA) Community Nursing Home (CNH) program provides in-person oversight monitoring the quality of care of veterans in VA-contracted community-based skilled nursing homes. The number of veterans receiving CNH care is projected to increase by 80% by 2037.

Methods: Retrospective observational data describing the distance between contracted facilities and VA medical centers (VAMCs) were linked to Centers for Medicare and Medicaid monthly Nursing Home Compare and Brown University Long Term Care: Facts on Care in the US data. Qualitative interviews with CNH-based staff and VA-based CNH program oversight team members were conducted using a semistructured interview guide. Quantitative and qualitative data were analyzed independently and integrated during the interpretation of results.

Results: The number of CNHs per VAMC ranged from 1 to 68 (mean, 18). One in 4 CNHs were > 70 miles from the associated VAMC; among CNHs with 2 to 5 veterans, 44% were located > 50 miles away. Four qualitative themes emerged regarding VA CNH oversight: (1) benefits of VA CNH team engagement/visits, including quality assurance and care coordination; (2) burden of VA CNH oversight due to geographic dispersion with too few or too many veterans at each to achieve efficiency; (3) oversight burdens and limited staffing restricted ability to add CNHs; and (4) remote access and interoperability of electronic health records and balancing the number of CNH veterans with staffing could facilitate successful oversight.

Conclusions: The success of the CNH program will depend on the exchange of information and matching available resources to veterans’ needs. At a time when strategies to ease the burden on NHs and VA CNH coordinators are needed, the VA needs to improve to properly scale the program.

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References

2. GAO. VA health care. Veterans’ use of long-term care is increasing, and VA faces challenges in meeting the demand. February 19, 2020. Accessed September 19, 2023. https://www.gao.gov/assets/gao-20-284.pdf

3. VHA Handbook 1143.2, VHA community nursing home oversight procedures. US Department of Veterans Affairs, Veterans Health Administration. June 2004. https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=3740930&FileName=VA259-17-Q-0501-007.pdf

4. Community care: veteran care agreements. US Department of Veterans Affairs. 2022. Updated August 8, 2023. Accessed September 7, 2023. https://www.va.gov/COMMUNITYCARE/providers/Veterans_Care_Agreements.asp

5. Massarweh NN, Itani KMF, Morris MS. The VA MISSION Act and the future of veterans’ access to quality health care. JAMA. 2020;324(4):343-344. doi:10.1001/jama.2020.4505

6. Colello KJ, Panangala SV; Congressional Research Service. Long-term care services for veterans. February 14, 2017. Accessed September 7, 2023. https://crsreports.congress.gov/product/pdf/R/R44697

7. Magid KH, Galenbeck E, Haverhals LM, et al. Purchasing high-quality community nursing home care: a will to work with VHA diminished by contracting burdens. J Am Med Dir Assoc. 2022;23(11):1757-1764. doi:10.1016/j.jamda.2022.03.007

8. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398-405. doi:10.1111/nhs.12048

9. Brown University. LTC Focus. Accessed September 18, 2023. https://ltcfocus.org/about

10. Zhang W, Creswell J. The use of “mixing” procedure of mixed methods in health services research. Med Care. 2013;51(8):e51-e57. doi:10.1097/MLR.0b013e31824642fd

11. Haverhals LM, Magid KH, Blanchard KN, Levy CR. Veterans Health Administration staff perceptions of overseeing care in community nursing homes during COVID-19. Gerontol Geriatr Med. 2022;8:23337214221080307. Published 2022 Feb 15. doi:10.1177/23337214221080307

12. Garvin LA, Pugatch M, Gurewich D, Pendergast JN, Miller CJ. Interorganizational care coordination of rural veterans by Veterans Affairs and community care programs: a systematic review. Med Care. 2021;59(suppl 3):S259-S269. doi:10.1097/MLR.0000000000001542

13. Schlosser J, Kollisch D, Johnson D, Perkins T, Olson A. VA-community dual care: veteran and clinician perspectives. J Community Health. 2020;45(4):795-802. doi:10.1007/s10900-020-00795-y

14. Nevedal AL, Wong EP, Urech TH, Peppiatt JL, Sorie MR, Vashi AA. Veterans’ experiences with accessing community emergency care. Mil Med. 2023;188(1-2):e58-e64. doi:10.1093/milmed/usab196

15. Levenson SA. Smart case review: a model for successful remote medical direction and enhanced nursing home quality improvement. J Am Med Dir Assoc. 2021;22(10):2212-2215.e6. doi:10.1016/j.jamda.2021.05.043

16. Donahue M, Bouhaddou O, Hsing N, et al. Veterans Health Information Exchange: successes and challenges of nationwide interoperability. AMIA Annu Symp Proc. 2018;2018:385-394. Published 2018 Dec 5.

17. US Department of Veterans Affairs. VHA Notice 2023-07. Community Nursing Home Program. September 5, 2023:1-4.

18. Helmer DA, Dwibedi N, Rowneki M, et al. Mental health conditions and hospitalizations for ambulatory care sensitive conditions among veterans with diabetes. Am Health Drug Benefits. 2020;13(2):61-71.

19. Rosen AK, Wagner TH, Pettey WBP, et al. Differences in risk scores of veterans receiving community care purchased by the Veterans Health Administration. Health Serv Res. 2018;53(suppl 3):5438-5454. doi:10.1111/1475-6773.13051

20. Mattocks KM, Kroll-Desrosiers A, Kinney R, Elwy AR, Cunningham KJ, Mengeling MA. Understanding VA’s use of and relationships with community care providers under the MISSION Act. Med Care. 2021;59(suppl 3):S252-S258. doi:10.1097/MLR.0000000000001545

The US Department of Veterans Affairs (VA) Community Nursing Home (CNH) program provides 24-hour skilled nursing care for eligible veterans in public or private community-based facilities that have established a contract to care for veterans. Veteran eligibility is based on service-connected status and level of disability, covering the cost of care for veterans who need long-term care because of their service-connected disability or for veterans with disabilities rated at ≥ 70%.¹ Between 2014 and 2018, the average daily census of veterans in CNHs increased by 26% and the percentage of funds obligated to this program increased by 49%.² The VA projects that the number of veterans receiving care in a CNH program will increase by 80% between 2017 and 2037, corresponding to a 149% increase in CNH expenditures.²

CNH program oversight teams are mandated at each VA medical center (VAMC) to monitor care coordination within the CNH program. These teams include nurses and social workers (SWs) who perform regular on-site assessments to monitor the clinical, functional, and psychosocial needs of veterans. These assessments include a review of the electronic health record (EHR) and face-to-face contact with veterans and CNH staff, regardless of the purchasing authority (hospice, long-term care, short-term rehabilitation, respite care).³ These teams represent key stakeholders impacted by CNH program expansion.

While the CNH program has focused primarily on the provision of long-term care, the VA is now expanding to include short-term rehabilitation through Veteran Care Agreements.⁴ These agreements are authorized under the MISSION Act, designed to improve care for veterans.⁵ Veteran Care Agreements are expected to be less burdensome to execute than traditional contracts and will permit the VA to partner with more CNHs, as noted in a Congressional Research Service report regarding long-term care services for veterans.⁶ However, increasing the number of CNHs increases demands on oversight teams, particularly if the coordinators are compelled to perform monthly on-site visits to facilities required under current guidelines.³

The objective of this study was to describe the experiences of VA and CNH staff involved in care coordination and the oversight of veterans receiving CNH care amid Veteran Care Agreement implementation and in anticipation of CNH program expansion. The results are intended to inform expansion efforts within the CNH program.

References

1. Miller EA, Gadbois E, Gidmark S, Intrator O. Purchasing nursing home care within the Veterans Health Administration: lessons for nursing home recruitment, contracting, and oversight. J Health Admin Educ. 2015;32(2):165-197.

2. GAO. VA health care. Veterans’ use of long-term care is increasing, and VA faces challenges in meeting the demand. February 19, 2020. Accessed September 19, 2023. https://www.gao.gov/assets/gao-20-284.pdf

3. VHA Handbook 1143.2, VHA community nursing home oversight procedures. US Department of Veterans Affairs, Veterans Health Administration. June 2004. https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=3740930&FileName=VA259-17-Q-0501-007.pdf

4. Community care: veteran care agreements. US Department of Veterans Affairs. 2022. Updated August 8, 2023. Accessed September 7, 2023. https://www.va.gov/COMMUNITYCARE/providers/Veterans_Care_Agreements.asp

5. Massarweh NN, Itani KMF, Morris MS. The VA MISSION Act and the future of veterans’ access to quality health care. JAMA. 2020;324(4):343-344. doi:10.1001/jama.2020.4505

6. Colello KJ, Panangala SV; Congressional Research Service. Long-term care services for veterans. February 14, 2017. Accessed September 7, 2023. https://crsreports.congress.gov/product/pdf/R/R44697

7. Magid KH, Galenbeck E, Haverhals LM, et al. Purchasing high-quality community nursing home care: a will to work with VHA diminished by contracting burdens. J Am Med Dir Assoc. 2022;23(11):1757-1764. doi:10.1016/j.jamda.2022.03.007

8. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398-405. doi:10.1111/nhs.12048

9. Brown University. LTC Focus. Accessed September 18, 2023. https://ltcfocus.org/about

10. Zhang W, Creswell J. The use of “mixing” procedure of mixed methods in health services research. Med Care. 2013;51(8):e51-e57. doi:10.1097/MLR.0b013e31824642fd

11. Haverhals LM, Magid KH, Blanchard KN, Levy CR. Veterans Health Administration staff perceptions of overseeing care in community nursing homes during COVID-19. Gerontol Geriatr Med. 2022;8:23337214221080307. Published 2022 Feb 15. doi:10.1177/23337214221080307

12. Garvin LA, Pugatch M, Gurewich D, Pendergast JN, Miller CJ. Interorganizational care coordination of rural veterans by Veterans Affairs and community care programs: a systematic review. Med Care. 2021;59(suppl 3):S259-S269. doi:10.1097/MLR.0000000000001542

13. Schlosser J, Kollisch D, Johnson D, Perkins T, Olson A. VA-community dual care: veteran and clinician perspectives. J Community Health. 2020;45(4):795-802. doi:10.1007/s10900-020-00795-y

14. Nevedal AL, Wong EP, Urech TH, Peppiatt JL, Sorie MR, Vashi AA. Veterans’ experiences with accessing community emergency care. Mil Med. 2023;188(1-2):e58-e64. doi:10.1093/milmed/usab196

15. Levenson SA. Smart case review: a model for successful remote medical direction and enhanced nursing home quality improvement. J Am Med Dir Assoc. 2021;22(10):2212-2215.e6. doi:10.1016/j.jamda.2021.05.043

16. Donahue M, Bouhaddou O, Hsing N, et al. Veterans Health Information Exchange: successes and challenges of nationwide interoperability. AMIA Annu Symp Proc. 2018;2018:385-394. Published 2018 Dec 5.

17. US Department of Veterans Affairs. VHA Notice 2023-07. Community Nursing Home Program. September 5, 2023:1-4.

18. Helmer DA, Dwibedi N, Rowneki M, et al. Mental health conditions and hospitalizations for ambulatory care sensitive conditions among veterans with diabetes. Am Health Drug Benefits. 2020;13(2):61-71.

19. Rosen AK, Wagner TH, Pettey WBP, et al. Differences in risk scores of veterans receiving community care purchased by the Veterans Health Administration. Health Serv Res. 2018;53(suppl 3):5438-5454. doi:10.1111/1475-6773.13051

20. Mattocks KM, Kroll-Desrosiers A, Kinney R, Elwy AR, Cunningham KJ, Mengeling MA. Understanding VA’s use of and relationships with community care providers under the MISSION Act. Med Care. 2021;59(suppl 3):S252-S258. doi:10.1097/MLR.0000000000001545

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